Features

Features

• Understanding Medicare vs. Medicaid vs. CHIP

  Medicare, Medicaid and CHIP are very influential in the healthcare industry at large, often steering trends in value-based care, social determinants of health and health equity.  Continue Reading

• Key MA quality bonus payment program outcomes, concerns

  Understanding the quality bonus payment program is critical to appreciating Medicare Advantage and discussing the calls for reform.  Continue Reading

• What are the differences between Medicare Parts A, B, C, D?

  Medicare includes four different segments that each insure a wide variety of services and supplies for enrollees.  Continue Reading

• Data, technology strategies boost payer patient education

  Analytics platforms, omnichannel engagement tools, telehealth, and other technological and data advancements have been pivotal to successful payer patient education.  Continue Reading

• A VBC approach to improving pediatric behavioral healthcare access

  Behavioral healthcare access for children and adolescents is lacking, but payers can use value-based care systems to increase and optimize referral opportunities.  Continue Reading

• How to accelerate value-based care despite looming healthcare crisis

  Centering provider and member experience will be key to accelerating value-based care in the coming years.  Continue Reading

• Keys to success in the Medicare Advantage health equity index

  The Medicare Advantage health equity index may not go into effect until 2027, but it will still affect payer strategies in 2024.  Continue Reading

• What to expect in the NSA’s independent dispute resolution process

  The No Surprises Act's independent dispute resolution process provides a channel for payers and providers to negotiate payments without affecting patient spending.  Continue Reading

• How do Medicare Advantage insurers craft population-specific health plans?

  Medicare Advantage insurers should prioritize data collection and provider collaboration when establishing population-specific health plans.  Continue Reading

• How are Medicare plans lowering drug costs for beneficiaries?

  Medicare and Medicare Advantage plans help lower drug costs for beneficiaries by establishing preferred pharmacy networks, promoting generic drug utilization, and working with PBMs.  Continue Reading

• How can payers be prepared to manage third-party security incidents?

  Payers should implement vendor management programs, incident response plans, and training processes to prepare for third-party security incidents.  Continue Reading

• How Payers and Pharmacy Benefit Managers Work Together to Lower Costs

  Pharmacy benefit managers negotiate prescription drug prices with drug manufacturers and pharmacies on behalf of payers.  Continue Reading

• Overcoming Tech Barriers to Achieve Prior Authorization Transparency

  Payers can use the next couple of years to establish a solid technology strategy to ensure compliance with the prior authorization final rule.  Continue Reading

• A Look Inside the Four Most Common Value-Based Care Arrangements

  Payers have several different value-based care arrangements they can offer, including pay-for-performance programs, bundled payment models, and capitation.  Continue Reading

• What Utilization Management Strategies Do Payers Use to Lower Costs?

  Utilization management strategies aim to lower healthcare costs and prevent low-value care but can have unintended consequences for patients.  Continue Reading

• Key Regulations and Policies That Will Impact Payers in 2024

  In 2024, payers must comply with Medicare Advantage marketing requirements, price transparency regulations, and prior authorization policies.  Continue Reading

• What Health Plans Are Available For People With Disabilities?

  Medicare and Medicaid are common health plan options for people with disabilities, though they must meet certain criteria before becoming eligible for coverage.  Continue Reading

• How Do Payers Cover Prenatal, Postpartum Care for Pregnant People?

  Public and private payers cover essential prenatal care for pregnant people, but coverage levels and costs may vary by plan.  Continue Reading

• Understanding Chronic Kidney Disease Coverage, VBC Opportunities

  Innovative and comprehensive chronic kidney disease coverage presents an opportunity to lower healthcare spending in the US.  Continue Reading

• How Can Payers Support Providers Through Workforce Challenges?

  Payers can implement value-based payment models and invest in training programs to support providers through workforce challenges.  Continue Reading

• How Public, Private Payers Cover Care for the LGBTQ+ Population

  Healthcare coverage for the LGBTQ+ population differs depending on a member’s state, health plan, and service needed.  Continue Reading

• Top Payer Concerns, Opportunities Around Generative AI Integration

  Payers should create a unified approach to AI overall, thoroughly document generative AI integration, and ensure the explainability of their generative AI tools.  Continue Reading

• 4 Key Strategies to Promote Effective Payer, Provider Alignment

  Data-sharing, value-based contracts, and standardized quality measures are critical to improving payer-provider alignment.  Continue Reading

• Demystifying Medicaid Managed Care, Its Role in the Future of VBC

  Medicaid managed care plans have gained traction as the dominant form of coverage in the Medicaid space with millions of beneficiaries in managed care organizations.  Continue Reading

• 3 Ways That Large Employers Influence Health Insurance Costs, Coverage

  Large employers can impact health benefit design, access to chronic disease management programs, and affordability of care.  Continue Reading

• What Technologies Support Payers With Claims Management Processes?

  Claims processing software, adjudication software, and health IT systems can streamline the claims management process for payers.  Continue Reading

• How to Evaluate Benefits to Ensure Health Equity for All Members

  Employers and health insurers need to evaluate their plans’ benefit designs for health equity to ensure that members are getting equal actuarial value.  Continue Reading

• How Do Payers Approach Care Management Strategies, Technologies?

  Leveraging EHR systems, telehealth tools, and data analytics can help payers improve care management strategies.  Continue Reading

• How the Top 4 Disruptive Insurtechs Have Evolved Since Their IPOs

  In a health insurance landscape that is consolidating into a few major players, four insurtechs sought to change the system.  Continue Reading

• Exploring the History of the Blue Cross Blue Shield Association

  The Blue Cross Blue Shield Association boasts 34 independent companies that provide healthcare coverage to people across the United States.  Continue Reading

• An Overview of the CMS AHEAD Model for Health Equity Advancement

  Participating states could receive as much as $12 million through the AHEAD model to align various payers on health equity goals.  Continue Reading

• How Quality Measures, Star Ratings Impact Healthcare Payers

  High performance on standardized quality measures like HEDIS and Medicare Advantage Star Ratings help consumers determine how to choose between healthcare payers.  Continue Reading

• Top 5 Largest Health Insurance Payers in the United States

  These top five health insurance payers hold the largest net revenue and members.  Continue Reading

• Employers Grapple with Workforce Mental Health Needs Post-Pandemic

  Mental health issues were the most commonly cited impact of COVID-19 and mental health initiatives were the highest priority for employers looking toward 2024.  Continue Reading

• Unpacking What Price Transparency Looks Like for Health Plans

  Health plans must sort through heaps of data to publish useful, accurate price transparency information for consumers.  Continue Reading

• How Payers Can Reduce Emergency Department Admission Rates, Costs

  To reduce emergency department admission rates, payers can implement virtual care, machine learning, and value-based care strategies.  Continue Reading

• Top Member Education Strategies for High Performance Network Benefits

  Member education strategies might vary based on whether the network is narrow or tiered, but clear communication is always necessary.  Continue Reading

• 4 Essential Components of Chronic Disease Management Strategies

  Chronic disease management requires strong disease management programs, care coordination, member education, and preventive care.  Continue Reading

• Value-Based Care and Fee-For-Service: What’s the Difference?

  Health plans reimburse providers based on quantity under fee-for-service models but prioritize quality in value-based care models.  Continue Reading

• Common Utilization Measures That Impact Value-Based Care Efforts

  Utilization measures such as emergency department use, hospital readmissions, and preventive care use are crucial to improving quality of care.  Continue Reading

• How Payers Can Identify Providers for High-Performing Networks

  Prioritizing data collection, technology, and provider engagement can help payers identify providers to include in high-performing networks.  Continue Reading

• How Plans Can Improve Race and Ethnicity Data Collection for HEDIS

  Empowering payer staff and prioritizing self-reported data are critical to race and ethnicity data collection.  Continue Reading

• How to Personalize Chronic Disease Management through Concierge Care

  Elevance Health changed its approach to chronic disease management with a digital-first concierge program.  Continue Reading

• 6 Key Payer Benefits that Support Behavioral Health Prevention

  Along with a strong provider network, payers can use these six strategies to promote behavioral health prevention.  Continue Reading

• What Employers Need to Know About ERISA Compliance for Health Plans

  ERISA compliance involves understanding the fiduciary role and the key health plan obligations that the law requires of employers.  Continue Reading

• The History of Medicare Advantage: From Inception to Growing Popularity

  Medicare Advantage offers beneficiaries supplemental benefits and out-of-pocket spending limits, two factors that may contribute to its growing popularity.  Continue Reading

• 3 Ways Payers Can Employ Machine Learning, Advanced Analytics

  Machine learning and advanced analytics have various uses in the health insurance industry, including condensing medical records, hypertargeting, and supporting risk adjustment.  Continue Reading

• Understanding the Different Metal Plans in the ACA Marketplace

  The metal plans in the ACA marketplace are required to provide coverage for the same essential health benefits but differ largely by healthcare costs, including monthly premiums, deductibles, and out-of-pocket expenses.  Continue Reading

• How Coverage, Costs Vary Within Different Types of Health Plans

  Different types of health plans, such as health maintenance organizations and preferred provider organizations, can lead to varying out-of-pocket expenses, monthly premiums, and annual deductibles for members.  Continue Reading

• How the Affordable Care Act Impacted the Individual Market

  The passing of the Affordable Care Act in 2012 shook up the individual health insurance marketplace and eight years later, the market is still feeling its impact.  Continue Reading

• 3 Ways Payers Drive Population Health Management in Cancer Care

  Population health management strategies such as precision medicine, coordinated care, and value-based payment models can improve patient outcomes.  Continue Reading

• How Payers Can Improve HEDIS Quality Measure Performance

  Population health management, health IT investment, and provider engagement need to be targeted to improve HEDIS quality measure performance.  Continue Reading

• The Progress and Challenges of the Affordable Care Act

  Various clauses of the Affordable Care Act brought obstacles for insurers to overcome.  Continue Reading